Recent WHO diabetes guideline summarized and critiqued

The updated guideline from the World Health Organization (WHO) included five recommendations,
some of which differed from ACP's most recent diabetes guideline.

The World Health Organization (WHO) released an updated diabetes guideline in July
and it was summarized by Annals of Internal Medicine on Sept. 4.

The guideline addresses treatment intensification in adults with type 1 or 2 diabetes
in low-resource settings in low- or high-income countries, as well as disadvantaged
populations in high-income countries. It was based on high-quality systematic reviews
and includes five recommendations:

Give a sulfonylurea to patients with type 2 diabetes who do not achieve glycemic control
with metformin alone or who have contraindications to metformin (strong recommendation,
moderate-quality evidence).

Introduce human insulin treatment to patients with type 2 diabetes who do not achieve
glycemic control with metformin and/or a sulfonylurea (strong recommendation, very
low-quality evidence).

If insulin is unsuitable, a dipeptidyl peptidase-4 (DPP-4) inhibitor, a sodium-glucose
cotransporter-2 (SGLT2) inhibitor, or a thiazolidinedione may be added (weak recommendation,
very low-quality evidence).

Use human insulin to manage blood glucose in adults with type 1 diabetes and in adults
with type 2 diabetes for whom insulin is indicated (strong recommendation, low-quality
evidence).

An editorial from ACP's High Value Care Committee was also published by Annals on Sept. 4 and analyzed some differences between the WHO guideline and ACP's 2017 diabetes guideline. The WHO guideline recommends sulfonylureas as second-line therapy based on effectiveness
and cost, but the editorialists “worry about the cumulative effect of hypoglycemia,”
they said. “The ACP recommends that clinicians and patients discuss benefits,
adverse effects, and costs when choosing among second-line therapy options, including
sulfonylureas, thiazolidinediones, SGLT-2 inhibitors, and DPP-4 inhibitors.”
Future research into the effects of newer diabetes drugs will likely lead to changes
in both guidelines, the editorial said.

Internal medicine physicians are specialists who apply scientific knowledge and clinical expertise to the diagnosis, treatment, and compassionate care of adults across the spectrum from health to complex illness. ACP Diabetes Monthly provides a monthly summary for internists about relevant news in diabetes. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.